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The Patient with Peripheral Vascular Disease

  • Raghubar P. Badola

Abstract

A 71-year-old woman with a history of insulin dependent diabetes mellitus and severe peripheral vascular disease was admitted with gangrene of the left big toe. The patient had undergone surgery one month previously for debridement of the toe and adjoining area. There was no history of trauma to the toe but the patient reported multiple infections at the site and had been treated with parenteral antibiotics. For the past year, the patient had experienced pain in her left calf on walking. She had expressive aphasia secondary to a cerebral vascular accident 6 months ago. There was no specific history of cardiac disease; she had never been told of hypertension. She had smoked heavily in the past but had stopped about 2 years ago. She enjoyed an occasional drink. Except for occasional hydrodiuril and “heart tablets,” she did not regularly take any prescribed drugs apart from regular insulin (dosage range 12–40 units, adjusted according to the blood sugar level) and a 2-week course of oxacillin.

Physical examination was significant for lack of all distal pulses, blood pressure, 175/100 mmHg, temperature: 99.5°F. The patient was acutely distressed and complained of considerable pain in her foot.

Laboratory findings were as follows: hematocrit 27.7, hemoglobin 9.5 gm, white blood count 10,200/mm3, serum electrolytes-potassium 4.7 mEq/L sodium 139 mEq/l, chloride 101 mEq/L, blood glucose 316 mg/dl, BUN 48 mq/dl, creatinine 2.1 mg/dl. Urine: negative for acetone; 2+ glucose. Angiogram revealed occlusion of the left tibioperoneal trunk and the posterior tibial artery. Electrocardiogram showed normal sinus rhythm with evidence of an old subendocardial infarction. Chest x-ray showed bilateral basal congestion.

Peripheral vascular disease with occlusion of the major vessels below the knee was diagnosed and the patient was scheduled for left femoral popliteal bypass graft.

Keywords

Chronic Obstructive Pulmonary Disease Peripheral Vascular Disease Significant Coronary Artery Disease Colloid Osmotic Pressure Cardiac Autonomic Neuropathy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Szilagyi DE: Vascular Surgery: A propaedeutic of its past, present and future, in Wilson, ES, Veith, FJ, Hobson, RW, Williams RA (eds): Vascular Surgery—Principles and Practice, New York: McGraw-Hill, pp 3–10, 1987.Google Scholar
  2. 2.
    Murray DWG, Best CH: The use of heparin in thrombosis. Ann Surg 1938; 108:163–77.PubMedCrossRefGoogle Scholar
  3. 3.
    Reid DD, Brett GJ, Hamilton PJS, et al: Cardiorespiratory disease and diabetes among middle aged male civil servants. Lancet 1974; i:469–73.CrossRefGoogle Scholar
  4. 4.
    Miller RD: Anesthesia for the elderly, in Miller RD (ed): Anesthesia, 2nd ed, New York: Churchill Livingston, pp 1801–18, 1986.Google Scholar
  5. 5.
    Marx GF, Mateo CV, Orkin L: Computer analysis of postanesthetic deaths. Anesthesiology 1973;39:54–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Wilson LA, Lawson R, Porass W: Multiple disorders in the elderly. Lancet 1962; 2:841–43.PubMedCrossRefGoogle Scholar
  7. 7.
    Hertzer NR, Beven EG, Young JR, et al: Coronary artery disease in peripheral vascular patients–a classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984; 199:223–33.PubMedCrossRefGoogle Scholar
  8. 8.
    Bloombery PA, Ferguson A, Rosengarten DS, et al: Role of coronary artery disease in complications of abdominal aortic surgery. Surgery 1987; 101: 250–55.Google Scholar
  9. 9.
    Hertzer NR: Fatal myocardial infarction following lower extremity revascularization —Two hundred and seventy three patients followed six to eleven postoperative years. Ann Surg 1981; 193:492–98.PubMedGoogle Scholar
  10. 10.
    Dormandy JA, Mahir MS: The natural history of peripheral atheromatous disease of legs, in Greenhalgh, RM, Jamieson Crawford, W, Nicolaids, AN (eds): Orlando: Grune & Stratton, Vascular Surgery issues in Current Practice, ed, 1986; pp 3–17.Google Scholar
  11. 11.
    Crawford ES, Bomberger RA, Glasser DH, et al: Aorto iliac occlusive disease: Factors influencing survival and function following reconstructive operation over a twenty five year period. Surgery 1981; 90:1055–67.PubMedGoogle Scholar
  12. 12.
    Vecht RJ, Nicolaides AN, Brandao E, et al: Resting and treadmill electrocardiographic findings in patients with intermittent claudication. Int Angio 1982; 1:119–21.Google Scholar
  13. 13.
    Reunanen A, Takkunen H, Aromma A: Prevalence of intermittent claudication and its effect on mortality. Acta Med Scand 1982; 211:249–56.PubMedCrossRefGoogle Scholar
  14. 14.
    Biland L, DaSilva A, Zemp E, et al: Occlusive peripheral artery disease (OPAD). Mortality and risk profile, in Proceedings of the 13th International Congress of Angiology, Athens, 9–14 June 1985.Google Scholar
  15. 15.
    Hertzer NR, Young JR, Kramer JR, et al: Routine coronary angiography prior to aortic reconstruction. Arch Surg 1978; 14:1336–44.Google Scholar
  16. 16.
    Malone JM, Moore WS, Goldstone J: Life expectancy following aorto-femoral arterial grafting. Surgery 1977; 81:551–55.PubMedGoogle Scholar
  17. 17.
    Gaensler EA, Weisel AD: The risk in abdominal and thoracic surgery. Postgrad Med 1973; 53:183.Google Scholar
  18. 18.
    White RA, Grundfest WS: LASERS in cardiovascular disease. Chicago: Year Book, Med Pub 1987.Google Scholar
  19. 19.
    Rao TLK, Jacobs KH, Adel AL: Reinfarction following anesthesia in patients with myocardial infarction. Anesthesiology 1983; 59:499–505.PubMedCrossRefGoogle Scholar
  20. 20.
    Steen PA, Tinker JH, Tarhan S: Myocardial reinfarction after anesthesia and surgery. JAMA 1978; 239:2566–70.PubMedCrossRefGoogle Scholar
  21. 21.
    Leppo J, Paja J, Gionet M, et al: Noninvasive evaluation of cardiac risk before elective vascular surgery. J Am Coll Cardiol 1987; 9:269–76.PubMedCrossRefGoogle Scholar
  22. 22.
    Baucher CA, Brewster DC, Darling RC, et al: Determination of cardiac risk by dipyridamole-thalium imaging before peripheral vascular surgery. N Engl J Med 1985; 321(7):389–94.CrossRefGoogle Scholar
  23. 23.
    Clements FM, deBruijn NP: Preoperative evaluation of regional wall motion by transesophageal two-dimensional echocardiography. Anesth Analg 1987;ii:66:249–61.PubMedCrossRefGoogle Scholar
  24. 24.
    Barash PG: Non-invasive cardiovascular monitoring. Ann Refresher Course Lectures, American Society of Anesthesiology, San Francisco, 1988, No. 411.Google Scholar
  25. 25.
    Kaplan JA, Wells PH: Early diagnosis of myocardial ischemia using the pulmonary artery catheter. Anesth Analg 1981; 60:789–93.PubMedGoogle Scholar
  26. 26.
    Ammon JR: Perioperative management of the diabetic patient. Annual Refresher Course Lectures, San Francisco, No. 215, 1988.Google Scholar
  27. 27.
    Little JM, Sheil AGR, Lowenthal J, et al: Prognostic value of intraoperative blood flow measurements in femoropopliteal bypass vein grafts. Lancet 1968; 648–51.Google Scholar
  28. 28.
    Yates CJP, Berent A, Andrews, H et al: Increase in blood flow by normovolemic hemodilation in intermittent claudication. Lancet 1979; 2:166–68.PubMedCrossRefGoogle Scholar
  29. 29.
    Nielsen OM, Engell HC: The importance of colloid osmotic pressure for interstitial fluid volume and fluid balance after elective abdominal vascular surgery. Ann Surg 1986; 203:25–29.PubMedCrossRefGoogle Scholar
  30. 30.
    Partridge BL: Use of pulse oximetry as a non-invasive indicator of intravascular volume status. J Clin Monit 1987; 3:263–68.PubMedGoogle Scholar
  31. 31.
    Rao TLK, El-Etr AA: Antiocoagulation following placement of epidural and subarachnoid catheters: an evaluation of neurologic sequelae. Anesthesiology 1981;55:618–20.PubMedCrossRefGoogle Scholar
  32. 32.
    Baron HC, LaRaja RD: Continous epidural analgesia in the Heparinized Vascular Surgical Patient: A Retrospective Review of 912 patients. J Vasc Surg 1987;6:144–46.PubMedCrossRefGoogle Scholar

Copyright information

© Birkhäuser Boston Inc. 1989

Authors and Affiliations

  • Raghubar P. Badola

There are no affiliations available

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